short and insightful writing about a long and complex history

The Authority of What Experience?

In most cases, people gain expertise through direct experience. This is not true when it comes to addiction, where legitimate expertise is derived from a lack of direct experience. There are many reasons for this, including cultural investment in educational prestige, faith in systems of authority, resentment of those who take their pleasure in what Derrida calls “an experience without truth,” and a distrust of addicts, who are “by class the most lying, scheming, dishonest group of patients.”

That quote about lying drug addicts is from this new report, “Addiction Medicine: Closing the Gap between Science and Practice,” which was released by the National Center on Addiction and Substance Abuse at Columbia University.

So when it comes to talking about addiction with any sort of legitimate authority, we generally turn to those with letters after their name rather than those with addiction in their background. The field of expertise has changed over time, from moral to legal to medical but, with very few exceptions, addicts have not been included in the cohort of experts.

If I may quote De Quincey, “worthy doctors, as there seems to be room for further discoveries, stand aside, and allow me to come forward and lecture on this matter”

Of course, there are exceptions. For a brief moment, when cocaine and opiates made their way into Europe and America, doctor-researchers tried the drugs themselves, reporting (often with great enthusiasm) about the amazing effects of the substances. And, following De Quincey, addict authors wrote cautionary narratives about their experiences. Plenty of creative individuals have sung and written about the trials and tribulations of addiction, but – as with De Quincey – their authority is derived from direct experience rather than through abstract education. There might be brief moments when these authors – including De Quincey – tell doctors that they don’t know what they don’t know, but their critique never extends beyond the autobiographical.

Then, in the mid-twentieth century, AA emerged as a workable solution to alcoholism and, later, other drugs and self-destructive activities. The twelve-step model relied on a humble and honest sort of authority and expressed wariness of any outside expertise, both because it hadn’t really worked and because any sort of grandiose claims of exceptionalism prevented the experience of hitting bottom. The twelve-step model has morphed far from the original definition of two alcoholics talking to each other; now it is a treatment modality seen in many recovery services. The twelve-step modality has become so widely accepted that when people talk about going into treatment, they are often referring to attending meetings.

According to a new five-year longitudinal study out of the National Center on Addiction and Substance Abuse, this assumption – that treatment means going to a meeting and relying on peer-support – is one of the reasons why addiction treatment is failing at such high rates. According to the study, medical providers are not trained in addiction medicine and treatment is not available to all who need it, which means that non-qualified people end up providing treatment services to those with no other real options. Those services are under-resourced, unregulated, not data-driven, and severely lacking in medical and scientific knowledge. In a quote that made it into most news reports about the study, this “continued failure” to address addiction and risky substance use in the health care community “constitutes a form of medical malpractice.”

Yes! I *commissioned* a cartoon just for this post! It was done by Kate Plows, who also does her own writing (about being an artist and a teacher). You can find her work here: http://teachingcraft.wordpress.com/

The authors of the study argue that addiction is a (brain) disease. It is a logical extension of the disease theory of addiction, which has gained credence thanks to recent advances in the attempt to locate addiction in the brain. As such, the report concludes, addiction should be treated by doctors. They would be responsible for screening, assessment, acute care, and management. Indeed, it is a doctor who would diagnose a person with addiction rather than, it is implied, the addict him- or herself.

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In addition to a doctor overseeing the treatment, a graduate-level therapist would provide mental health treatment, and nurses and physician’s assistants would provide case management. The report argues that all treatment institutions must have a “full-time certified addiction physician on staff” and that even counselors must have at least a bachelor’s degree. Less important is any sort of “personal experience with addiction,” what has traditionally been considered a counselor’s “trump card.”

The report makes some exciting interventions into the way we think about addiction. Instead of expanding the definition of addiction to include more and more experiences, it limits the term by separating addiction from use. Its new taxonomy distinguishes between addiction, which is a “chronic” relapsing “brain disease,” and “risky” substance use, which belongs in the realm of public heath. It’s refreshing to see at least conceptual space for harm reduction interventions, even if the term only appears once in the entire 323-page report. This taxonomy also recognizes the spectrum of experience ranging from substance use to “mild” to “severe” addiction. The report also draws attention to the fact that most people cannot afford treatment and that insurance coding makes it hard for someone to return to treatment after the original course of care has ended.

yes, I mixed my metaphor, but it’s not as bad as it could be.

But something is missing from this picture. When we carve up the pie that is addiction treatment, where do we put twelve-step, peer-run recovery groups? Do they still get a place at the table?

The report’s authors consider AA and NA under the heading of “mutual support services” and note that they can be a “significant part of a comprehensive approach” to treatment. Most significantly, they are free and accessible, which is not true of more medical-based approaches. The evidence of their effectiveness, however, is only anecdotal because they are hard to study due to their anonymous nature and the impossibility of getting a randomized sample of participants. Without data to prove their effectiveness, these programs remain in a medical limbo and, as a result, cannot be seen as a purely viable option. Another problem with these resources is that counselors who follow this model because it worked for them are often both resistant to outside intervention and unqualified to shift to “evidence-based practices.” Therefore, these peer-support services “do not qualify as treatment for a medical disease.” Since they will never count as a medical treatment, twelve-step models can only be counted as “support services,” not as treatment.

Ouch. That’s a pretty bold conclusion, and I’m surprised there wasn’t more of an uproar about it. After all, it relegates the biggest player in the field to bat boy or cheerleader.

It would be easy to take some jabs at the report, which ingenuously suggests at one point that a doctor is “optimally situated” to refer an addict to medical treatment. As if addicts all have access to a personal doctors and complete faith in medical authority! What about the anti-authoritarian tendencies of many active users? What about the addict identity as a point of counter-cultural pride? What about reports that doctors have hardly any time to talk to patients already? What about harm reduction’s wise suggestion to “treat people where they are at,” which is almost certainly not a doctor’s office. And, of course, what if addiction is not simply a brain disease, but a cultural manifestation? After all, the definition and the lived experience of addiction are both embedded deeply in culture.

To me, the most interesting part of this report is how it sets competing notions of expertise into bold relief. Do we value the non-experiential expertise of academics and doctors? Or do we value the authority of hard-won experience with addiction and recovery? Must these two things be mutually exclusive?

At the risk of sounding ridiculously idealistic, it seems to me that we need many modalities if we are to reach every addict who wants to get sober. Narrowing the definition of addiction so that it is only a crime or sickness or brain disease, and then yanking that limited definition into only the field intended to address that particular metaphorical construct of addiction is never going to work. Addiction exceeds brain scans or diagnostic questionnaires. It exceeds self-diagnosis and denial. It will never be a-historical or a-cultural. I don’t believe anyone will be able to point to a brain scan or any other test and say, “there.”

So as long as we can’t really say, “there,” maybe we need to meet addiction itself where it’s at? Letting go of the idea that there is one there there would require valuing all the different sorts of expertise we may find, whether it is in a meeting or a doctor’s office. It would mean that pure data is not the only way to measure treatment success. It might also mean that we could devote our energies to getting rid of the really bad programs and learning from the ones that work, no matter what source provides the expertise.

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3 thoughts on “The Authority of What Experience?”

Addiction can be likened, in many ways, to the common cold. The common cold is a disease; it is widespread; most people “afflicted” with it recover without the assistance of medical professionals, and for that matter, any other intervention. We don’t know what causes the common cold and we don’t have evidentially based cures for it. However, there are hundreds of “cures” offered for the common cold — from old wive’s tales to internet driven offers of expensive remedies, and dozens of suggested interventions to reduce symptoms while the disease runs its course. (For a fun afternoon, search the Cochrane Abstracts for titles including “common cold”)

As to the belief that The Twelve Steps is not amenable to research, I recommend that readers of this blog check out the many research articles by Rudolf Moos, and John F. Kelly and their respective associates. They are perhaps the most prolific researchers in a growing field of those interested in the role of spirituality in organized interventions for problems of addiction. Whether Spirituality or Placebo — it works when you work it🙂

My most recent casual review of CASA Columbia’s Annual Report and key personnel are enough to support my ongoing belief that they are far more interested in making noise than doing research. There are many more qualified organizations examining the many roles of medicine in the problem of addiction. Having observed this group since their formation by a retired government lawyer, I have yet to see any substantial original research produced by them. I do, however, notice recent references to neuroscience in their literature. Another bandwagon on which to jump.

It’s understandable that addicted people lie, manipulate, bluff, and avoid to minimize immediate and/or potential problems in their lives while keeping a focus on securing future substance use.
What I find interesting is that many of these same people, at some point in their lives, will make a very singular and well thought out decision about future use that completely “cures” the addiction forever – “I will never use again”. It is certainly an unusual medical disease that can be permanently cured with the “patient” applying a particular sort of brain wave activity that, in its essence, lasts about ten seconds. This is a very real brain changer, too. New neural pathways regarding future using get well ingrained as time passes, and even dream states are effected.

There is a problem in getting statistics on these “cures” that goes even beyond the-boy-who-cried-wolf data deciphering because, not only have those addicts previously lied to others about making that very commitment, but, when they finally DO make the commitment to never use again, there’s no way to know for sure whether they really did it unless they are permanently implanted with a real-time blood monitor that would signal a drug level back to headquarters. (I suspect this technology and social justification for its “voluntary” use is just around the corner)

Also, many people labor under the false belief that former addicts don’t have the capacity to know themselves whether they REALLY mean it when they say “I will never use again, and I will never change my mind.”

Nevertheless, it would seem to make sense that the huge field of human services applied to people because of their addictions could certainly include the optional goal of making it as clear and easy as possible for addicts to make that good old fashioned teetotalers pledge.

I look forward to hearing about more research surrounding brain changes leading up to and caused by making The Pledge.

Some reflections on this great post from my perspective as a medical student and an ethnographer of drug use. At Harvard, they required med students to attend a 12-step group — usually AA or NA– to learn about how these groups work (not going to problematize that here) but clearly they believe in its efficacy for some. Many or most of the physicians I have been exposed to in clinical settings believe AA and NA “work” for many people. Furthermore, there is little exposure to addiction medicine in medical school curricula and many primary care physicians feel ill-equipped to handle the often overwhelming social complexities presented by drug use– short of possibly recommending methadone or buprenorphine-naloxone, and thus the AA and NA recommendations. In some fieldwork I’m doing, I’ve accompanied some women to their NA groups and I do believe it offers a community of individuals at various stages of working through ‘recovery’ and a much more accessible forum for people ‘trying to save their lives” than the doctor’s office, closed during all the hours when drug use and relapse are most likely to occur.